Transcript
RISK Summer 2009
Michigan Do Not Resuscitate Orders Model Policy
Michigan Municipal Risk Management Authority Fire/EMS Advisory Committee
MICHIGAN DO NOT RESUSCITATE ORDERS Recent trend analyses show that a portion of the population prefers that no medical intervention be performed, and that the natural process of death be allowed to take its course.
INTRODUCTION More and more, Americans are deciding how they prefer to be treated in the days, hours, and minutes preceding their own deaths. Advances in both prehospital and in-hospital medical care have given doctors the ability to “extend” lives, even when an illness or injury would soon prove to be fatal. It is legally assumed that a patient wants life-saving measures performed under any circumstances. Emergency and healthcare professionals are obligated to go to extremes in treatment and care. Recent trend analyses show that a portion of the population prefers that no medical intervention be performed, and that the natural process of death be allowed to take its course. When a person makes such a decision and wants no intervention, he/she must complete certain documents and make them available to family members, pre-hospital care providers, and medical care facilities in order for those wishes to be followed. BACKGROUND In 1996, Governor John Engler signed legislation that allows terminally ill patients outside of hospitals or nursing homes in Michigan to request that they not be resuscitated if they experience heart and respiration failure. “A terminally ill individual has the right to decide if extreme measures should be taken to prolong their life,” Engler said. “This legislation assures them that, if it is their will, they will be allowed to die without intervention.” The legislation that passed includes three bills, Senate Bills 451, 452 and 836: • Senate Bill 452, sponsored by Senator John Schwarz, M.D. (R-Battle Creek), creates a new act, the Michigan Do-Not-Resuscitate Procedure Act. The bill provides for an individual, or a
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patient advocate of an individual, who is at least 18 years old, to establish a do-not-resuscitate order. The order is a signed document directing that, in the event that a patient suffers cessation of both spontaneous respiration and circulation in a setting outside of a hospital, nursing home, or mental health facility owned or operated by the Department of Community Health, no resuscitation will be initiated. The bill provides for a do-not-resuscitate bracelet and requires that a bracelet or actual order be present for an order to be carried out. • Senate Bill 431, sponsored by Senator Dale Shugars (R-Portage), amends the Public Health Code to prohibit a health facility/agency from requiring the execution of a do-not-resuscitate order as a condition for admission or receipt of services. • Senate Bill 836, also sponsored by Senator Shugars, amends the Adult Foster Care Facility Licensing Act to provide that a licensee providing foster care to a resident who was enrolled in a licensed hospice program with an assessment plan that includes a do-not-resuscitate order is considered to be providing protection to the resident if the resident suffered from heart and respiratory failure and resuscitation was not initiated. The legislation received unanimous bipartisan support in the legislature as well as the backing of the following organizations: the Family Independence Agency, the Michigan Health and Hospital Association, the Michigan Hospice Association, Right-to-Life of Michigan, the Michigan State Medical Society, the Michigan Nurses Association, the Michigan Association of Ambulance Services, the Michigan Catholic Conference, the Michigan Residential Care Association, Angela Hospice, ARC, and the Michigan Protection and Advocacy Service.
DEFINITIONS (the following are excerpts of PA 192 and 193 of 1996) “Do-Not-Resuscitate Order” means a document … directing that in the event that a patient suffers cessation of both spontaneous respiration and circulation in a setting outside of a hospital, a nursing home, or a mental health facility owned and operated by the Department of Community Health, no resuscitation will be initiated. “Do-not-resuscitate identification bracelet” or “identification bracelet” means a wrist bracelet that … is worn by the declarant while a do-notresuscitate order is in effect. At any time after an order is signed and witnessed, the declarant or an individual designated by the declarant may apply an identification bracelet to the declarant’s wrist. A “do-not-resuscitate identification bracelet” shall possess features that make it clearly recognizable as a do-not-resuscitate identification bracelet, including, but not limited to: • The identification bracelet shall be imprinted with the words “DO-NOT-RESUSCITATE ORDER,” and the name and telephone number of the declarant’s attending physician, if any. NOTE: The words required above shall be printed in a type size and style that is as easily read as practical, given the size of the identification bracelet. Revocation of Order. “A declarant, or patient advocate who executes an order on behalf of a declarant, may revoke an order at any time and in any manner by which he or she is able to communicate an intent to revoke the order. If the revocation is not in writing, a person who observes the revocation shall describe the circumstances of the revocation in writing and sign the writing. Upon revocation, the declarant, patient advocate, or attending physician or a delegatee of the attending physician who has actual knowledge of the revocation shall destroy the order and remove the declarant’s do-not-resuscitate identification bracelet, if the declarant is wearing a do-not-resuscitate identification bracelet.”
SAMPLE EMS PROTOCOL Upon arrival at the scene: 1. Determine if the declarant has no vital signs. This means no pulse or evidence of respiration. 2. Determine that the declarant is wearing a DoNot-Resuscitate Identification Bracelet and/ or that you have been provided with a DoNot-Resuscitate Order executed by or for the declarant in compliance with the applicable statute.
EMS should follow the direction of law enforcement regarding movement of the body and clearing the scene.
3. If it is determined that the declarant has no vital signs and that the declarant is wearing a Do-Not-Resuscitate Identification Bracelet and/ or that you have been provided with a DoNot-Resuscitate Order, DO NOT ATTEMPT RESUSCITATION OF THE DECLARANT. 4. If the declarant is enrolled in an approved Hospice Program and the hospice nurse is present at the scene, the nurse will make the required reports to law enforcement and the medical examiner’s office. If a hospice nurse is not present at the scene, follow the procedures in #5 below. 5. If the declarant is not an enrolled hospice patient, follow local procedures for the notification of law enforcement and the medical examiner. EMS should follow the direction of law enforcement regarding movement of the body and clearing the scene. 6. Complete thorough documentation, including presentation of the Do-Not-Resuscitate Order/ Identification Bracelet, and the time death was declared or pronounced by the hospice nurse or physician. In every case in which a patient is not transported to a hospital, the audit copy of the run report must be turned in to the applicable medical control authority for review within 72 hours.
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A Michigan law provides that these documents are valid in settings other than hospitals or nursing homes.
FREQUENTLY ASKED QUESTIONS (FAQ)
For whom might such a document be particularly useful? A hospice patient who is home to die as peacefully as possible might wish to sign a Do-Not-Resuscitate (DNR) declaration.
Must they be terminally ill before signing a DNR declaration? No. For example, they may be in good health but still not want to be resuscitated should their heart and lungs fail.
Are such documents legally binding? Yes. A Michigan law provides that these documents are valid in settings other than hospitals or nursing homes.
Are there standard forms for a DNR declaration? Yes. One form provides spaces for a doctor to sign, for the declarant to sign, and for two witnesses to sign. There is an alternate form for individuals who have religious beliefs against using doctors.
Can a patient advocate sign the form instead of the declarant? If a patient advocate has authority to act, he or she can sign the form instead of the declarant.
Is it necessary to have a DNR declaration if the individual has a durable power of attorney or living will? Perhaps. A durable power of attorney for health care and a living will only take effect when a person is unable to participate in treatment decisions. If a person is competent until the moment their heart and breathing stop, these documents will never take effect.
What else can be done to prevent unwanted resuscitation? Declarants should ask relatives, in advance, NOT to call 911 or the police if the declarant’s breathing should stop. If under the care of a registered nurse, the nurse has the authority to pronounce death.
What about a declarant in a nursing home or hospital? These facilities can set their own policies about resuscitation. Upon admission or thereafter, patients should express their wishes on this issue and ask that these wishes be reflected on their medical charts.
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Who may complete a Do-Not-Resuscitate Order? A competent adult who has discussed the issue with his/her physician. The physician must also sign the order. People whose religion opposes medical treatment don’t need a doctor’s signature.
Where are the DNR forms available? The forms are available from most hospices and online at relevant websites.
When properly documented, a DoNot-Resuscitate Order is a legal instrument designed to ensure the wishes of a person who is in life’s final stages.
Can someone be forced to sign a Do-Not-Resuscitate Order? Absolutely not. No one may require it as a condition for care or treatment.
Can a declarant change their mind after signing a DNR Order? Yes. They may cancel it at any time by any means of communication possible.
Will my insurance coverage be affected if I sign such an order? No. The law says that your insurance provider can’t change, stop, refuse to renew, or invoke a suicide exemption or exclusion.
CONCLUSION Emergency response personnel are often summoned to scenes where critically ill or injured patients are unable to communicate and are given life-saving medical treatments under the legal assumption that the treatments are desired by the patient. When
this is not the case, but no contrary documentation is available, emergency responders may be confronted be family members trying to intervene on behalf of the patient. These confrontations can become serious when emotions are involved and adrenaline is elevated. When properly documented, a Do-NotResuscitate Order is a legal instrument designed to ensure the wishes of a person who is in life’s final stages. The patient, his/her family, and any health care personnel are bound by the wishes stated by the order.
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SAMPLE DNR ORDER (without physician signature) I request that, in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order is effective until it is revoked by me. Being of sound mind, I voluntarily execute this order, and I understand its full import. ________________________________________________________ (Declarant’s signature and date) ________________________________________________________ (Type or print declarant’s full name) _________________________________________________________ (Signature of person who signed for declarant, if applicable, and date) _________________________________________________________ (Type or print full name) ATTESTATION OF WITNESSES The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the individual has/has not (circle one) received an identification bracelet. _____________________________________________ (Witness signature) (date) _____________________________________________ (Type or print witness’s name) _____________________________________________ (Witness signature) (date) _____________________________________________ (Type or print witness’s name)
This form was prepared pursuant to, and in compliance with, the Michigan Do-Not-Resuscitate Procedure Act. (From the University of Michigan Health System)
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SAMPLE DO-NOT-RESUSCIATE ORDER (with physician signature) I have discussed my health status with my physician, ____________________________. I request that, in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order is effective until it is revoked by me. Being of sound mind, I voluntarily execute this order, and I understand its full import. _________________________________________________________ (Declarant’s signature and date) _________________________________________________________ (Type or print declarant’s full name and date) _________________________________________________________ (Signature of person who signed for declarant, if applicable, and date) _________________________________________________________ (Type or print full name) __________________________________________________________ (Physician’s signature and date) __________________________________________________________ (Type or print physician’s full name)
ATTESTATION OF WITNESSES The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the individual has (has not) received an identification bracelet. _________________________________________________________ (Witness signature and date) _________________________________________________________ (Type or print witness’s name) _________________________________________________________ (Witness signature and date) _________________________________________________________ (Type or print witness’s name) This form was prepared pursuant to, and in compliance with, the Michigan Do-Not-Resuscitate Procedure Act. (From the University of Michigan Health System)
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FIRE/EMT ADVISORY COMMITTEE MEMBERS Chief Michael Rorabacher (Chair) Canton Fire Department
Chief William Nelson Troy Fire Department
Captain Gregory Flynn West Bloomfield Twp. Fire Department
Director Gerald Champagne Van Buren Public Safety
Chief Richard Marinucci Northville Twp. Fire Department
Captain Joseph Dell Southfield Fire Department
Chief William Steele Green Oak Fire Department
Deputy Chief Robert Hudson Portage Fire Department
Captain Kevin Dunham Dearborn Heights Fire Department
Medic Phillip Kamm Livonia Fire Department
Deputy Chief Jeff VanDellen Grand Rapids Fire Department
Captain Dave Garland Redford Twp. Fire Dept.
Chief Bill Forbush Garden City Fire Department
Michael Rhyner, Executive Director MMRMA
Chief Andrew Pless Howell Area Fire Department
MMRMA Committee Liaison Al Smolen Risk Consultant, MMRMA
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